075601300-6-16-2025-15-AS-HHUL-DK2NNH-20250729103645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601300
Report Date: 06/16/2025
Date Signed: 06/16/2025 03:06:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2025 and conducted by Evaluator Tonica Syess-Gibson

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20250307165508

FACILITY NAME:	WESTMONT OF BRENTWOOD		FACILITY NUMBER:	075601300
ADMINISTRATOR:	AGUSTIN SAMANIEGO		FACILITY TYPE:	740
ADDRESS:	450 JOHN MUIR PKWY		TELEPHONE:	(925) 516-8006
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	200	CENSUS: 100	DATE:	06/16/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Scott Shahade, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not obtain doctor's order for medication.
Staff is not administering medication to a resident.
Resident lost weight.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 06/16/2025 at 1:30PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver findings for the above allegations. LPA met with Scott Shahade, Executive Director and explained the purpose of the visit.

During the course of the investigation, LPAs T. Syess-Gibson and L. Hall interviewed staff, LPAs was unable to interview resident (R1) due to diagnosis on physician report (LIC602). Admission agreement, physician's report, medication list, service plan, staff schedule, staff roster with contact numbers, weight log for R1, R2 and R3, R1’s Electronic Medication Administration Record (E-MAR) and august health report were reviewed and obtained.

Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 15-AS-20250307165508

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WESTMONT OF BRENTWOOD	FACILITY NUMBER: 075601300
	VISIT DATE: 06/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099

Staff did not obtain doctor's order for medication.

During investigation LPAs interviews with staff, and reviewed records, during interviews it was revealed that there was a period of time when the facility waiting for the resident’s doctor to authorize the medication. During record review it was revealed one of R1’s medication wasn’t listed on LIC602 (physician report) dated in December 2024, however, was listed on the new LIC602. LPAs also reviewed documentation of communication between the facility and R1’s physician regarding orders of medication.

Staff is not administering medication to a resident.

During investigation LPAs interviews with staff and it was revealed R1 missed some days of taking the medication because the facility was waiting for authorization from R1’s physician to administer the medication. The facility had two physician’s report, one with the medication listed and the other without medication listed.

Resident lost weight.

During investigation LPAs reviewed R1’s Physicians Report (LIC602) and it was revealed during record review the medication R1 was prescribed causes weight loss and R1 was on a restricted diet per doctor orders.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2